More Medications Means Changes to HIV Treatment Guidelines


The HIV treatment update includes more considerations for coinfected patients and pregnant women than the previously published 2011 guidelines.

It has been just over a year since The United States Department of Human and Health Services updated guidelines for the treatment of patients with HIV.1 The FDA approval of more medications for HIV treatment and the availability of new formulations to decrease the pill burden of patients with HIV have prompted changes in the HIV guidelines. The HIV treatment update includes more considerations for coinfected patients and pregnant women than the previously published 2011 guidelines.

For Initial Combination Regimens for the Antiretroviral-Naive Patient, the addition of tenofovir alafenamide/ emtricitibine (TAF/FTC) (approved in 2016) as a 2-NRTI option after trials demonstrated the 1-pill combo has less of a negative effect on bone mineral density and kidney function (serum creatinine, phosphate and uric acid excretion, protein and albumin in the urine) while maintaining efficacy in virologic suppression.

Lopinavir/ritonavir (LPV/r) plus 2-NRTI regimen was removed from the list of other regimens because regimens containing this protease inhibitor (PI) combination have a larger pill burden and greater toxicity than other currently available options.

In the HIV Infected Women and Pregnancy, guidelines reiterated antiretroviral therapy (ART) for early treatment during pregnancy and continuation of ART after pregnancy. The guideline details new data on interactions between antiretroviral (ARV) drugs and hormonal contraceptives.

The new guideline has expanded information for treatment of the coinfected HIV population. When treating patients with tuberculosis(TB)/HIV, a 12-week course of once-weekly rifapentine and isoniazid is an option for patients receiving either an efavirenz (EFV)- or a raltegravir (RAL)-based regimen.

Data from the TEMPRANO and START studies demonstrating a potential role of ART in reducing TB disease supported the revised recommendation.

Another recommendation is the avoidance of rifamycins due to their potent induction of P-glycoprotein and tenofovir alafenamide (TAF) being a P-gp substrate.

In the hepatitis B/HIV coinfected patient, TAF/FTC is listed as a treatment option for patients with HBV/HIV coinfection and adefovir or telbivudine is no longer recommended as options for HBV/HIV coinfected patients, as there is limited safety and efficacy data on their use in this population. In addition, these agents have a higher incidence of toxicities than other recommended treatments.

For patients who are coinfected with hepatitis C and HIV, the guideline includes additional information regarding potential pharmacokinetic (PK) interactions between different ARV drugs and the recently approved hepatitis C drugs daclatasvir and the fixeddose combination product elbasvir/grazoprevir (EBR/GZR). Also, peginterferon alfa and ribavirin were removed from the guideline’s list of possible interactions with selected HIV drugs due to these agents not having significant pharmacokinetic interactions with ARV drugs.

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